Claims Examiner II

Job Title: Claims Examiner II

Target Compensation Range: $70,000 - $80,000/year, depending on the level of relevant qualifications and experience.

About Us:

Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.

SUMMARY: Under the direction of the Vice President of Claims, this position is responsible for manual input and adjudication of claims submitted to the health plan. The ideal candidate will need to interpret and utilize capitation contracts, payor matrixes, subscriber benefit plan, and provider contracts; as well as resolving customer service inquiries, status calls, and claim tracers.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

• Accurately reviews, research, and analyzes professional, ancillary, and institutional inpatient and outpatient claims. Process all types of claims, such as HCFA 1500, outpatient/inpatient UB92, high dollar claims, and DRG claims.
• Knowledge of CPT/HCPC and ICD-9/ICD-10 code and guidelines. This includes Revenue Codes and Modifiers.
• Data enter paper claims into EZCAP.
• Review and interpret provider contracts to properly adjudicate claims.
• Review and interpret Division of Financial Responsibility (DOFR) of claims processing.
• Perform delegated duties in a timely and efficient manner.
• Verify eligibility and benefits as necessary to properly apply co-pays.
• Strong working knowledge of Medicare and Medi-Cal, OPPS APC, Ambulatory Surgery pricing, and RBRVS payment guidelines.
• Understands eligibility, enrollment, and authorization processes.
• Knowledge of prompt payment guidelines for clean and unclean claims.
• Process claims efficiently and maintains the acceptable quality of at least 95% on reviewed claims.
• Meets daily production standards set for the department and meet weekly check run deadlines.
• Prepare claims for medical review and signature review per processing guidelines.
• Identify the correctly received date on claims, with knowledge of all time frames for meeting compliance requirements for all lines of business.
• Maintains good working knowledge of system/internet and online tools used process claims.
• Ability to identify and report processing inaccuracies that are related to system configuration
• Research authorizations and properly selects the appropriate authorization for services billed.
• Coordinate Benefits on claims for which the member has another primary coverage.
• Requests for additional information or follow-up with providers for incomplete or unclean claims.
• May resolve claims payment issues as presented through Provider Dispute Resolution (PDR) process or from claim inquiries.
• Documents resolution of claims to support claim payment and/or decision.
• Run monthly reports.
• Review pre and post check run.
• Collaborate with other departments and/or providers in successful resolution of claims-related issues.
• Coordinate with the claims clerks on issues related to the submission and forwarding of claims determined to be financial responsibility of another organization.
• Ability to effectively communicate with External and Internal teams to resolve claims issues.
• Regular and consistent attendance
• Other duties as assigned

EDUCATION and/or EXPERIENCE:

• High School Diploma or GED required.
• 3 to 5 years of previous experience in a health plan, IPA or medical group.
• Strong understanding of the benefit process including member services or customer service.
• Demonstrated proficiency in MS Office (Excel, Word, Outlook, and PowerPoint).
• Able to navigate difficult situations with empathy, discretion, and professionalism.
• Strong understanding of Senior Medicare Advantage Health plans.
• Able to explain member benefits, answer questions and concerns using a “Customer Service First” attitude.
• Able to live our mission, vision, and values,
• Bilingual in another language (written and oral) preferred.

BENEFITS:

• 401(k)
• Dental Insurance
• Health Insurance
• Life Insurance
• Vision Insurance
• Paid Time Off